1. Early Recognition and Management of Sepsis for HHS
Meeting 4
Pat Posa RN, BSN, MSA, CCRN-K, FAAN
Quality Excellence Leader
SJMHS

2. Early Recognition and Management of Sepsis
Welcome
Program design
Evidence-based and best practice education and training on protocols and tools necessary for early recognition of sepsis
Interactive and integrated team approach with all health professionals
Case-based approach
Utilizes Performance Improvement Plan
Includes home health agencies and discharging facility
Required data collection over the period of the improvement project and beyond and includes how to track and trend the data

3. Early Recognition and Management of Sepsis
Results: participating agencies implementing a sepsis protocol such that:
Improved screening and identification of septic patients receiving home health services
Improved identification of patients with sepsis
Improved early interventions for patients with sepsis
Reduced admission or readmission (30 and 90 days)
Reduce the severity of sepsis when admission is required
Assessment of current infection prevention practices for pneumonia, UTI’s and wounds
Implement one infection prevention practice to close the gap between current state and best evidenced based practice for each infection
Reduce mortality rates for those with sepsis (save lives)
Agency Expectations:
Implement sepsis screening tool and treatment protocols as provided in Early Recognition and Management of Sepsis Program
Participate in monthly learning sessions
Participate in a coaching call between session 1 and 2
Submission of process data

4. Program overview Pre-work prior to first session (watch a video)
3 in-person 90 minute session (consecutive months)
1 virtual 60 minute session
One coaching call between session 1 and 2

5. What We Did Last Meeting
Review homework related to implementation and auditing of sepsis screening
Discuss infection prevention strategies for PNA, UTI and wounds
Reviewed homework:
Perform current state assessment on PNA, UTI and wound infection prevention
Complete sepsis screening audits

6. Agenda for Today’s Meeting
Review results of the current state assessment on PNA, UTI and wound infection prevention
Discuss how the sepsis screening implementation is going and the results of the sepsis screening audits
Review ongoing data submission process

7. Wound: Current State Assessment
Prevention Practices
Current Policy or Procedure in Place
Audit 5 patients to see if compliant with policy
Clinical staff wound care training (agency)
Policy/Procedure:
Proper hand hygiene
Policy:
Proper dressing change technique (incl. cleansing)
Procedure:
Proper nutrition screening and requirements identified (incl. hydration)
EB dressing selection
Clinical indications for obtaining a wound culture
Pressure Ulcer Screening
Skin impairment prevention plans in place
Proper identification of support surface(s)
Patient and caregiver education plans in place
Use of wound care certified or trained professional*
Professional wound committee*
*Recommended but not required

8. Current State Assessment related to PNA Prevention Practices
Current Policy in Place
Audit 5 patients to see if compliant with policy
Proper hand hygiene
Comprehensive Oral Care
Prevention of Aspiration
Swallow screens
Proper positioning during eating/feeding and sleep
Mobility/ Lung expansion
(up at least 1/day)
Adequate nutrition
(consumed >50% of diet)

9. Current State Assessment Related to UTI/CAUTI Prevention Practices
Current Policy in Place
Audit 5 patients to see if compliant with policy
Proper Hand Hygiene
Without Indwelling Catheter:
adequate fluid so urine is light and clear
Appropriate toileting (emptying bladder every 2-3 hrs)
Incontinence management
With Indwelling Catheter:
Aseptic technique followed during insertion
Daily catheter care
Catheter secured
Closed system
No dependent loops
Catheter bag not on floor

10. Round Robin
Review results of the current state assessment on PNA, UTI and wound infection prevention
What gaps did you identify? What are your strategies to close the gaps?
Discuss how the sepsis screening implementation is going and the results of the sepsis screening audits

11. Ongoing Data Submission Process
Submit excel spread sheet to MPRO on the 15th of the month for the prior month’s audits
Use this address _______________

12. Sepsis Early Recognition Action Plan

13. Sepsis patient education toolkit

14. Sepsis Audit Sepsis screening compliance rate
MEASURE NAME
PERFORMANCE REVIEW MEASURES
MEASURE DEFINITION/FORMULA (NUMERATOR/DENOMINATOR)
Sepsis screening compliance rate
Percent of unique patient visits where the SEPSIS screening tool was performed (performed 1 day per week, randomly)
Numerator = Number of unique patient visits where the SEPSIS screening tool was performed Denominator = 30
Residents screened correctly using sepsis screening tool
Percent of unique patient visits where the SEPSIS screening tool was performed accurately and reliably i.e. the screening tool was done correctly in a standardized format
Numerator = Number of unique patient visits where the SEPSIS screening tool was performed correctly Denominator = Number of unique patient visits that were audited for SEPSIS screening accuracy (min=5)

15. Thank you for your hard work and dedication to preventing infection and sepsis in the people we care for